Editor s Desk High rate of immediate systemic hypersensitivity reactions to tiger snake antivenom

High rate of immediate systemic hypersensitivity reactions to tiger snake antivenom 419 Geoffrey K Isbister, Alan S Tankel, Julian White, Mark Little, Simon G A Brown, David J Spain, Chris F Gavaghan, Bart J Currie 420 Jane Leong An African strain of community methicillin-resistant Staphylococcus aureus in a Burundi refugee 420 Annabelle Donaldson, Iain B Gosbell Invasive meningococcal disease presenting with cellulitis 421 Karina J Kennedy, Jhumur Roy, Paul Lamberth Professional development of registrars 422 Jagdishwar Singh Effective shade structures 423 Kay R Coppa, John S Greenwood Chronic heart failure: time to optimise methods of diagnosis in the community 423 Heather H Buchan, Susan M Phillips, Lynn M Weekes, Judith M Mackson, Andrew N Boyden, Andrew M Tonkin

High rate of immediate systemic hypersensitivity reactions to tiger snake antivenom Geoffrey K Isbister, Alan S Tankel, Julian White, Mark Little, Simon G A Brown, David J Spain, Chris F Gavaghan and Bart J Currie TO THE EDITOR: During a national multicentre study of snake bites the Australian Snakebite Project (ASP), involving over 40 hospitals we have recently noted a high rate of early allergic reactions following the administration of tiger snake antivenom in Australia. People with suspected The or definite Medical snake Journal envenoming of Australia are recruited ISSN: to ASP, 0025-729X and laboratory 17 April 2006 and clinical data 306- and 312 serial blood samples are col- 184 8 lected The to measure Medical venom Journal and of antivenom Australia concentrations. 2006 www.mja.com.au Letters From 1 November 2005 to 31 January 2006, 14 patients who had been given tiger snake antivenom (CSL Limited, Parkville, VIC) were recruited. These patients are briefly described in the Box, and include bites from several different groups of snakes. Of the 14 patients, 11 exhibited immediate systemic hypersensitivity reactions to antivenom infusion. Reactions were mild in five patients, moderate in three, and severe in three, according to the grading system by Brown. 1 The six patients in the moderate and severe groups fulfilled the criteria for anaphylaxis according to a recent consensus definition. 2 All patients required specific treatment in addition to ceasing antivenom therapy, and nine were treated with adrenalin. Antivenom was recommenced in all patients at a slower rate, although an adrenalin infusion was required in four of these and repeat doses of intramuscular or subcutaneous adrenalin in another four while the antivenom infusion continued. Over the same period, there were seven administrations of brown snake antivenom (over 30 vials of antivenom) reported to ASP without any hypersensitivity reactions. There has been a previous report of allergic reactions to tiger snake antivenom in a single hospital, 3 and we are concerned that there may be a particular problem with tiger snake antivenom. The reaction rate in this series is similar to reported rates in parts of the world where high reaction rates have been attributed to relatively impure antivenom preparations. 4,5 The reactions here were traced to at least four different batches of tiger snake antivenom. Fourteen patients administered tiger snake antivenom for snake envenoming Age/sex Previous antivenom Snake Clinical features Grading Treatment of reaction 47 M No; SH BHS No reaction Nil Nil 13 M No TSG No reaction Nil Nil 17 M No TSG Nil Nil Nil 20 M No TSG Generalised erythema, urticaria, tachycardia We have informed CSL of this high rate of reactions and the antivenom batch numbers, and we have encouraged the treating doctors to make formal reports of each adverse reaction to CSL and the Adverse Drug Reactions Advisory Committee. Health care professionals treating patients with tiger snake antivenom need to be aware of the possible higher risk of anaphylaxis with tiger snake antivenom and be prepared to treat with adrenalin. Recommendations for the diagnosis and treatment of anaphylaxis have recently been reviewed. 6 However, this current problem with CSL tiger snake antivenom should not cause health professionals to reduce or cease its use. In all patients described here, control of the adverse reaction and continuation of antivenom was possible. The rapid identification of this problem over a short period was only possible because of our large multicentre collaborative study, and supports such studies for recognising uncommon envenoming syndromes. Mild Competing interests IM adrenalin (0.5 mg), then IV adrenalin infusion 12 M No RBBS Generalised erythema Mild IM adrenalin (0.2 mg 3) 12 M No RBBS Generalised erythema, urticaria 28 F No TSG Pruritus, erythema and moist cough (no wheeze) Mild Mild IM adrenalin (0.25 mg 2) Promethazine (10 mg) 53 M No TSG Generalised pruritus Mild Promethazine (25 mg) 32 M No TSG Dizziness, chest tightness, Mod. SC adrenalin (0.3 mg) tachycardia, vomiting 21 M Yes; SH SBS Generalised rash and pruritus, vomiting 9 M No SBS Urticarial rash, chest tightness 55 M No; SH PHS Generalised pruritus, diaphoresis, confusion, hypotension M No RBBS Rash, wheeze and hypotension 45 F No TSG Hypotension, sweaty and unwell appearance Mod. Mod. Severe Severe Severe IV adrenalin infusion for 1 hour IV adrenalin infusion SC adrenalin (0.5 + 0.5 + 1 mg), IV fluid, IV hydrocortisone (100 mg) Adrenalin, IV fluid, antihistamines, steroids IV adrenalin infusion BHS = Broad-headed snake (Hoplocephalus bungaroides); IM = intramuscular; IV = intravenous; Mod. = moderate; PHS = Pale-headed snake (H. bitorquatus); RBBS = Red-bellied black snake (Pseudechis porphyriacus); SBS = Stephens banded snake (H. stephensii); SC = subcutaneous; SH = snake handler; TSG = Tiger snake group (any snake from the Notechis, Hoplocephalus, Tropidechis, and Austrelaps genera). Julian White is employed by the Women s and Children s Hospital, Adelaide, which is paid by CSL Ltd to provide a clinical toxinology service for users of CSL antivenom and venom detection products. Geoffrey K Isbister, Senior Research Fellow; and Clinical Toxicologist 1 Alan Tankel, Director 2 Julian White, Associate Professor; and Head of Toxinology 3 Mark Little, Clinical Toxicologist and Emergency Physician 4 Simon G Brown, Associate Professor; and Emergency Physician 5 David J Spain, Emergency Physician 6 Chris F Gavaghan, Director 7 Bart J Currie, Head, Tropical and Emergency Infectious Disease Division; and Professor in Medicine 1 1 Menzies School of Health Research, Charles Darwin University, Darwin, NT. 2 Emergency Department, Coffs Harbour Base Hospital, NSW. MJA Volume 184 Number 8 17 April 2006 419

3 Women's and Children's Hospital, Adelaide, SA. 4 Sir Charles Gairdner Hospital, Perth, WA. 5 Fremantle Hospital, Perth, WA. 6 Gold Coast Hospital, Southport, QLD. 7 Emergency Department, Lismore Base Hospital, NSW. Correspondence: gsbite@ferntree.com 1. Brown SG. Clinical features and severity grading of anaphylaxis. J Allergy Clin Immunol 2004; 114: 371-376. 2. Sampson HA, Munoz-Furlong A, Campbell R, et al. Second symposium on the definition and management of anaphylaxis: summary report. J Allergy Clin Immunol 2006. In press. 3. Tankel AS. Anaphylaxis associated with the same batch of tiger-snake antivenom. Med J Aust 2001; 174: 608-610. 4. Gawarammana IB, Kularatne SAM, Dissanayake WP, et al. Parallel infusion of hydrocortisone ± chlorpheniramine bolus injection to prevent acute adverse reactions to antivenom for snakebites: a randomised, double-blind, placebo-controlled study. Med J Aust 2004; 180: 20-23. 5. Lalloo DG, Theakston RD. Snake antivenoms. J Toxicol Clin Toxicol 2003; 41: 277-290. 6. Brown SGA. Anaphylaxis: clinical concepts and research priorities. Emerg Med Australas 2006. In press. Jane Leong COMMENT: Thank you for the opportunity to comment on the letter by Isbister et al regarding hypersensitivity reactions to tiger snake antivenom. CSL has been notified about the cases of hypersensitivity reactions to tiger snake antivenom in general, but has only received two individual case reports. We have been in contact with the study investigators and have requested more detailed information on the other patients so that we can further our investigations. A thorough check of product manufacturing records revealed no deviations from approved specifications for tiger snake antivenom. It is important to note Isbister et al have advised health professionals not to reduce or cease the use of tiger snake antivenom. We would like to draw physicians attention to the approved Product Information before use of the product. The tiger snake (and other antivenom) Product Information lists the possibility of both anaphylactic and anaphylactoid reactions. Hypersensitivity and skin reactions (including urticaria, rash, hypotension, bronchospasm, anaphylaxis and delayed serum sickness) are listed as common, and are more likely to occur in people who have had previous exposure to equine-based products. In addition, the Product Information describes an anaphylactoid reaction which can occur because the antivenom has the ability to bind complement. The risk of this reaction can be minimised by adequate dilution of the antivenom (1 : 10 for adults and 1 : 5 in small children) before infusion. Further, the Product Information states that a syringe already loaded with 1: 1000 adrenalin must be available during antivenom therapy. CSL is continuing to monitor this situation closely and is awaiting further details on the patients from the reporting physicians. In the meantime, we encourage users of all antivenom products to report any untoward reaction to CSL so that these can be fully evaluated. Jane Leong, Medical Director CSL Pharmaceuticals Limited, Melbourne, VIC. Correspondence: jane.leong@csl.com.au An African strain of community methicillin-resistant Staphylococcus aureus in a Burundi refugee Annabelle Donaldson and Iain B Gosbell TO THE EDITOR: Community strains of methicillin-resistant Staphylococcus aureus (MRSA) are increasingly seen in Australia, particularly in certain population subgroups, such as Pacific Islander 1 and Aboriginal 2 people. We report the case of an African with community MRSA to highlight its existence in yet another subgroup. Given the increase in people arriving in Australia from Africa under the Humanitarian Program (with around 8500 arrivals from Africa in 2004 2005) 3 and their wide dispersal around the country, it is possible that African community MRSA will be seen increasingly in Australia. A 53-year-old Burundi refugee presented with an infected wound overlying the left lateral malleolus after laceration 6 weeks previously in a Tanzanian refugee camp. An unknown antibiotic was given for 2 weeks before travel to Australia. On the patient s arrival in this country, the wound appeared purulent, erythrocyte sedimentation rate was 82 mm/h (reference range [RR] < 10 mm/h), and C-reactive protein level was 9 IU/L (RR < 5 IU/L). Plain x-rays and bone scans suggested osteomyelitis. A wound swab grew S. aureus, Streptococcus pyogenes and Pseudomonas species. The patient was initially given intravenous cefazolin, and then definitive therapy (for MRSA and S. pyogenes, ignoring the colonising pseudomonad) with oral clindamycin (450 mg three times daily). Clinical resolution was complete, and levels of acute-phase reactants returned to normal. The antibiotic sensitivity pattern of the S. aureus isolate raised suspicion that it might be an unusual strain: it was resistant to methicillin, tetracycline and trimethoprim sulfamethoxazole, but sensitive to erythromycin, clindamycin, ciprofloxacin, gentamicin, vancomycin, linezolid, mupirocin, rifampicin, fusidic acid and chloramphenicol. The meca gene was detected by polymerase chain reaction testing, confirming methicillin resistance. The organism possessed staphylococcal cassette chromosome mec (SCCmec) element type IV. The Panton Valentine leukocidin gene, staphylococcal enterotoxins A to E and toxic shock syndrome toxin-1 were not detected. As DNA fingerprinting with standard pulsed-field gel electrophoresis showed a novel banding pattern, the gold standard of multilocus sequence typing was used for identification. This confirmed an ST140 allelic profile, which has not been seen previously in Australia. 4 On the balance of probabilities, the isolate represents an African community MRSA strain, not previously detected in Australia. Non-multiresistant community MRSA is not widely recognised in African countries. Hospital MRSA rates vary widely in Africa (eg, between 21% and 30% of all S. aureus isolates in Nigeria, Kenya and Cameroon, and fewer than 10% in Tunisia and Algeria 5 ), but most are multiresistant. Medical practitioners in Australia who treat African refugees need to be aware that pyogenic soft tissue infections could be caused by community MRSA, and these MRSA strains may have a different antibiotic sensitivity profile to Australian community MRSA strains. It is essential to take appropriate specimens for microbiological analysis (wound swabs and possibly blood cultures and/or tissue samples), as antibiotic susceptibility profiles are increasingly unpredictable. 420 MJA Volume 184 Number 8 17 April 2006

Acknowledgements We thank Joanne Mercer, Thelma Barbagiannakos, Robert Porritt and Yvonne Kwok (South Western Area Pathology Service, Liverpool, NSW) for performing pulsed-field gel electrophoresis and polymerase chain reaction testing for meca and virulence genes; Flavia Huygens, Phil Giffard and Alex Stephens (Cooperative Research Centre for Diagnostics, Queensland University of Technology, Brisbane, QLD) for performing multilocus sequence and SCCmec typing; and Mitchell Smith (Refugee Health Service, Sydney South West Area Health Service Western Zone, NSW) for supplying data about refugees. Annabelle Donaldson, MB ChB, Infectious Diseases Registrar 1 Iain B Gosbell, MD, FRACP, FRCPA, Director; 2 and Conjoint Associate Professor 3 1 Liverpool Health Service, Sydney, NSW. 2 Department of Microbiology and Infectious Diseases, South Western Area Pathology Service, Sydney, NSW. 3 Faculty of Medicine, University of New South Wales, Sydney, NSW. Correspondence: i.gosbell@unsw.edu.au 1. Nimmo GR, Schooneveldt J, O Kane G, et al. Community acquisition of gentamicin-sensitive methicillin-resistant Staphylococcus aureus in southeastern Queensland, Australia. J Clin Microbiol 2000; 38: 3926-3931. 2. Riley TV, Pearman JW, Rouse IL. Changing epidemiology of methicillin-resistant Staphylococcus aureus in Western Australia. Med J Aust 1995; 163: 412-414. 3. Australian Government Department of Immigration and Multicultural Affairs. Fact sheet 60: Australia s refugee and humanitarian program. 2005. Available at: http://www.immi.gov.au/facts/ 60refugee.htm (accessed Feb 2006). 4. MLST. Multi locus sequence typing. Available at: http://saureus.mlst.net (accessed Nov 2005). 5. Kesah C, Ben Redjeb S, Odugbemi TO, et al. Prevalence of methicillin-resistant Staphylococcus aureus in eight African hospitals and Malta. Clin Microbiol Infect 2003; 9: 153-156. Invasive meningococcal disease presenting with cellulitis Karina J Kennedy, Jhumur Roy and Paul Lamberth TO THE EDITOR: We recently treated two patients with invasive meningococcal disease presenting with cellulitis. This presentation contributed to a delay in diagnosis and appropriate antibiotic treatment. Cellulitis in Patient 1 Cellulitic area on the right thigh of a 33-yearold woman with Neisseria meningitidis meningitis. The first patient was a 33-year-old woman, recently diagnosed with nephrotic syndrome, who had been unwell for a week with mild upper respiratory tract symptoms. During this time, her nephrologist began treating her with prednisolone (15 mg daily). The day before presentation, she developed abdominal pain, vomiting, chills, myalgia and headache. A rash developed on the day she presented to hospital. The temperature was 39.2 C, heart rate 148 beats per min, and blood pressure 146/57 mmhg. She had an area, measuring 20 cm 20 cm, of tender cellulitic rash on the right thigh (Box) and mild neck stiffness. The diagnosis was initially unclear, leading to a delay of several hours before ceftriaxone was administered, and a lumbar puncture performed. Cerebrospinal fluid (CSF) examination revealed a leukocyte count of 4500 10 6 /L (98% polymorphs) (reference range [RR], < 5 10 6 /L), gramnegative diplococci, and protein concentration of 2073 mg/l (RR, 150 450 mg/l). The patient subsequently required intensive care admission for non-invasive ventilation and inotropic support. Neisseria meningitidis serotype C was detected in the CSF by polymerase chain reaction testing. The patient was discharged well except for mild headache and lethargy after 6 days. At 1-week review, she remained lethargic but was otherwise well. The rash was slowly resolving. The second patient was a 51-year-old woman with fever and a 2-day history of progressive pain, swelling and erythema of the anterolateral area of the neck. The temperature was 38.5 C, heart rate 115 beats per min, and blood pressure 134/86 mmhg. There was no evidence of upper airway involvement. The anterior area of the neck and upper chest wall were swollen, erythematous, tender and warm. No fluid collections or masses were detected on ultrasound examination. The patient was admitted to hospital with a diagnosis of cellulitis, and treatment was begun with intravenous flucloxacillin and metronidazole. After 17 hours, culture of blood taken on admission showed N. meningitidis serotype W135. Antibiotic treament was changed to ceftriaxone. After 5 days, the patient had mild residual inflammation and tenderness of the neck. She completed another week of treatment with oral amoxycillin. Only 14 cases of N. meningitidis cellulitis have been published. 1-3 Seven cases involved children with periorbital cellulitis. In adults, three cases involved the face and neck, and four the limbs. N. meningitidis was isolated from blood (eight patients), conjunctival swabs (three), aspirates of the cellulitic areas (two) or CSF (one). There was one death: an elderly woman with bacteraemia and cellulitis of the face and neck. 2 As illustrated by our cases, the many guises of meningococcal disease continue to challenge clinicians. Karina J Kennedy, MB BS, Microbiology Registrar 1 Jhumur Roy, MB BS, FRCPA, Microbiologist 1 Paul Lamberth, MB BS, FACEM, Director of Intensive Care 2 1 The Canberra Hospital, Canberra, ACT. 2 Calvary Healthcare ACT, Canberra, ACT. Correspondence: karina.kennedy@act.gov.au 1. Porras MC, Martinez VC, Ruiz IM, et al. Acute cellulitis: an unusual manifestation of meningococcal disease. Scand J Infect Dis 2001; 33: 56-59. 2. Cartolano GL, Barbier C, Arnoult L, et al. Fatal acute cellulitis due to Neisseria meningitidis. J Clin Microbiol 2003; 41: 3996-3997. 3. Chand DV, Hoyen CK, Leonard EG, McComsey GA. First reported case of Neisseria meningitidis periorbital cellulitis associated with meningitis. Pediatrics 2005; 116: e874-e875. MJA Volume 184 Number 8 17 April 2006 421

Professional development of registrars Jagdishwar Singh TO THE EDITOR: The CanMEDS 2000 report 1 and its 2005 revision 2 have emphasised that effectiveness as a medical specialist requires competencies in addition to clinical and medical expertise. These include being a communicator, collaborator, manager, health advocate, scholar and professional. Building the non-clinical skills of doctors has been the focus of a professional development project in Australia that is targeting registrars. Junior doctors usually step up to the role of registrar in the 3rd year of their prevocational training. A national workshop convened by the Postgraduate Medical Council of Victoria in March 2004 agreed on a framework for the professional development of registrars, comprising the following 10 competencies: leadership; communication skills; supervision; mentoring; teamwork; self-awareness and empathy; time management; problem solving; professionalism and ethics; and safety and quality. 3 To provide content for these competencies, a job-shadowing exercise involving two registrars at two different Victorian hospitals was undertaken in April 2005 to get a first-hand understanding of the roles of medical registrars as managers. The registrars were voluntary participants, and permission was obtained from all participants. I shadowed the two registrars during their entire 9-hour shifts. No major issues arose in relation to the shadowing process itself, and the consultants overseeing the two registrars were extremely accommodating in this process. The two observed registrars authenticated the veracity of the recorded observations. The observations from the job-shadowing exercise were clustered into competencies using the framework developed for the professional development of registrars discussed above. The Box summarises these observations and highlights the range of registrar interactions that are influenced by non-clinical competencies. While the small number of registrars is an obvious limitation of the study, this jobshadowing exercise did demonstrate that managerial skills, knowledge and behaviour represent a significant component of the work of clinicians, especially as they move up the medical hierarchy. This assertion should not be misconstrued as suggesting that the clinical skills and knowledge become any less important. As noted in the 2005 CanMEDS framework, the medical expert role is the central role for doctors. It is also worth noting here that some pilot professional development programs con- Observations during job-shadowing of two registrars at two Victorian hospitals Competency Supervision Leadership Communication skills Time management Problem solving Professionalism and ethics Teamwork Mentoring Self-awareness and empathy Safety and quality Observed interactions Reviewing patient treatment plans and test results and prescribing a course of action Ensuring that procedures are followed Coaching intern on test procedures, completion of patient records, etc Giving ongoing feedback to intern Delegating tasks to intern Coordinating patient treatment with other units Dealing with other health professionals, some of whom take directions from the registrar, as well others over whom there is no formal authority Providing advice to intern and role modelling desired behaviour Demonstrating the ability to respond quickly and with confidence Involving subordinates and providing opportunities for them to participate in decision making Using networking skills with other departments Using negotiating skills in dealing with other departments, hospitals, etc Using communication skills with patients, intern, medical colleagues, other health care professionals, and service departments Dealing with cross-cultural diversity issues with patients, their families, and staff Using negotiating skills in dealing with other departments, hospitals, patients, and family members Using recording skills to ensure treatment plans properly documented for others Prioritising patient list for ward rounds The constant need to re-assess priorities during ward rounds, in light of time constraints The ability to deal with constant interruptions from other colleagues, to provide necessary clarifications Making decisions on patients continued treatment or discharge, and stipulating any follow-up action Task contingency management skills to deal with patient treatment plans not proceeding as planned Dealing with information gaps in patient historical records Involving intern and other staff to assist in the decision-making process and raising issues with consultant Dealing with demarcation issues with other doctors and professionals Role modelling professional behaviour to patients, staff, and the public Balancing the interests of patients with hospital needs, without sacrificing patient trust Obtaining patient consent for procedures Coordinating treatment plans with other doctors and health professionals Sharing information and agreeing on treatment plans with allied health staff Joint meeting with other colleagues to advise a patient and family members on surgical procedures and associated risks Ability to work in both collaborative and individual modes during the day Providing advice to intern to be more assertive and confident when dealing with consultant Patience and empathy in giving bad news to family Dealing with patients who are aged or mentally or physically challenged Knowledge and application of safe practices in relation to patient management Ensuring that procedures are followed, such as obtaining consent, ordering of tests, etc Reviewing records before dispensing treatment Recording treatment plans and medications 422 MJA Volume 184 Number 8 17 April 2006

ducted recently as part of the registrar project show that registrars welcome training that enhances their non-clinical skills, especially when provided professionally in an environment conducive to learning. Jagdishwar Singh, PhD, Project Manager Postgraduate Medical Council of Victoria, Melbourne, VIC. Correspondence: jsingh@pmcv.com.au 1. CanMEDS 2000 project. Skills for the new millennium: report of the Societal Needs Working Group, September 1996. Available at: http://rcpsc.medical.org/publications/index.php (accessed Feb 2006). 2. Royal College of Physicians and Surgeons of Canada. CanMEDS 2005 framework. Available at: http://rcpsc.medical.org/canmeds/bestpractices/ framework_e.pdf (accessed Feb 2006). 3. Postgraduate Medical Council of Victoria. Professional development of registrars supervising junior medical staff: final project report. October 2004. Available at: http://www.medeserv.com.au/pmcv/ download/download.cfm/final_report 18 Oct.pdf?txtLibraryID=pmcv&txtFileName=Final_ Report_18_Oct.pdf (accessed Feb 2006). Effective shade structures Kay R Coppa and John S Greenwood TO THE EDITOR: We were pleased to read Turnbull and Parisi s short piece on the effectiveness of shade structures, highlighting the challenges of ensuring adequate and effective shade protection, particularly in children s settings. 1 Cancer councils in various states have long recognised these challenges and provided assistance to those who design or manage facilities for children, in the form of training workshops, resources and guidelines. Epidemiological evidence indicates that childhood exposure to ultraviolet (UV) radiation is a strong determinant of risk of melanoma but there is also evidence of its contribution to the development of nonmelanocytic skin cancer. 2,3 It is estimated that living in Australia for the first 15 years of life contributes about two-thirds of the lifetime risk of melanoma of a lifelong resident. 4 Sun exposure in childhood, especially that leading to sunburn, is the main environmental determinant of the number of melanocytic naevi. An individual s number of naevi is the strongest measurable predictor (after age and ethnicity) of risk of melanoma. 5 Our publication, Under Cover, referred to by Turnbull and Parisi, is one such resource, developed as a comprehensive reference tool for anyone involved in shade planning and design in New South Wales and has been adapted for use in other states by state cancer councils. 6 Turnbull and Parisi comment that Under Cover provides inappropriate advice regarding the use of deciduous trees, as solar UV radiation levels can be hazardous during winter in subtropical Queensland. As might be expected, the NSW edition of Under Cover does not address winter solar protection issues in northern Queensland. We note that the requirements for effective shade cited by Turnbull and Parisi are identical to those prescribed in Under Cover. For those interested in determining when UV protection is required throughout the year in different locations, an interactive shade planning software program will be available shortly at <www.webshade.com.au>. In it, ShadeCalendar recommends what type of shade would be most appropriate for comfort and solar protection in different months of the year. The Bureau of Meteorology now issues the SunSmart UV Alert when the UV Index is forecast to reach 3 or above, highlighting when sun protection is required (www.bom.gov.au/products/uvindex_ national.shtml). The SunSmart UV Alert is reported in most newspaper, television and radio weather forecasts across Australia. Shade is only one of a range of sun protection strategies recommended by the Cancer Council. With Australia having the highest skin cancer rates in the world, general practitioners play a pivotal role in providing sun protection counselling advice to parents of children aged 1 13 years. 7 The Cancer Council NSW recommends a range of sun protection measures including UV avoidance during the peak UV times (10:00 14:00 or 11:00 15:00 during daylight saving time), shade, clothing, hats, sunglasses and use of sun protection factor 30+ broad spectrum, water resistant sunscreen. Competing interests John Greenwood owns shares in, and is a Director of, WebShade Pty Ltd. Kay R Coppa, MPH, Manager 1 John S Greenwood, Director 2 1 Skin Cancer Prevention, The Cancer Council NSW, Sydney, NSW. 2 WebShade Pty Ltd, Sydney, NSW. Correspondence: kayc@nswcc.org.au 1. Turnbull DJ, Parisi AV. Effective shade structures. Med J Aust 2006; 184: 13-15. 2. Marks R, Jolley D, Lectsas S, Foley P. The role of childhood sunlight exposure in the development of solar keratoses and non-melanocytic skin cancer. Med J Aust 1990; 152: 62-65. 3. MacKie RM. The pathogenesis of cutaneous malignant melanoma. BMJ 1983; 287: 1568-1569. 4. Armstrong BK. Melanoma: childhood or lifelong sun exposure. In: Grobb JJ, Stern RS, Mackie R, Weinstock MA, editors. Epidemiology, causes and prevention of skin diseases. Sydney: Blackwell Science, 1977. 5. Dennis LK, White E, Lee JAH, et al. Constitutional factors and sun exposure in relation to nevi: a population-based cross-sectional study. Am J Epidemiol 1996; 143: 248-256. 6. Greenwood JS, Soulos GP, Thomas ND. Under cover: guidelines for shade planning and design. Sydney: Cancer Council NSW, NSW Health Department, 1998. 7. Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice (the red book). 6th ed. Melbourne: RACGP, 2005. Available at: http://www.racgp.org.au/redbook/ (accessed Mar 2006). Chronic heart failure: time to optimise methods of diagnosis in the community Heather H Buchan, Susan M Phillips, Lynn M Weekes, Judith M Mackson, Andrew N Boyden and Andrew M Tonkin TO THE EDITOR: Investigators in the recent Canberra Heart Study 1 highlighted the importance of improving the detection of heart failure in the community, given the high proportion of people with preclinical disease. The accompanying editorial 2 expressed concern about the lack of major Australian initiatives that focus on the prevention and treatment of this disease. We fully endorse the authors view that under-recognition and under-treatment of heart failure is an important national issue. While we support their call for sustained and adequately funded programs, we feel it is important to note that there are initiatives under way to attempt to improve the situation. The National Prescribing Service, the National Heart Foundation of Australia and the National Institute of Clinical Studies joined forces in 2004 to improve the diagnosis and management of heart failure in primary care. A national program, undertaken in partnership with 45 divisions of general practice, began in October 2004 and will conclude in early 2006. 3 Nationally, the program provided newsletter materials to all general practitioners, pharmacists and physicians. 4 In participating divisions, educational outreach visits and interactive small group meetings involved over 1600 GPs and local specialists in discus- MJA Volume 184 Number 8 17 April 2006 423

sions of the role of echocardiography in diagnosis, and pharmacological and lifestyle management issues. Patient education materials were also widely disseminated. 5 Outcomes of this largescale quality improvement program are currently being evaluated, and results are expected to be available in early 2007. Other groups have also recognised heart failure as an important issue for example, it is one of the featured conditions in the Department of Veterans Affairs Medicines Advice and Therapeutics Education Services program. 6 Heather H Buchan, MBChB, MSc, FAFPHM, Chief Executive Officer 1 Susan M Phillips, DPhil, Senior Program Manager 1 Lynn M Weekes, BPharm, MSc, PhD, Chief Executive Officer 2 Judith M Mackson, BPharm, MMedSci(ClinEpi), Education and Quality Assurance Manager 2 Andrew N Boyden, MBBS(Hons), MPH, FRACGP, Medical Affairs Manager 3 Andrew M Tonkin, MBBS, MD, FRACP, Chief Medical Officer 4 1 National Institute of Clinical Studies, Melbourne, VIC. 2 National Prescribing Service, Sydney, NSW. 3 National Heart Foundation of Australia, Canberra, ACT. 4 National Heart Foundation of Australia, Melbourne, VIC. Correspondence: sphillips@nicsl.com.au LETTERS 1. Abhayaratna WP, Smith WT, Becker NG, et al. Prevalence of heart failure and systolic ventricular dysfunction in older Australians: the Canberra Heart Study. Med J Aust 2006; 184: 151-154. 2. Krum H, Stewart S. Chronic heart failure: time to recognise this major public health problem. Med J Aust 2006; 184: 147-148. 3. Phillips SM, Davies JM, Tofler G. NICS Heart Failure Forum: improving outcomes in chronic care. Med J Aust 2004; 181: 297-299. 4. National Prescribing Service Limited. Improving drug use in heart failure program. Available at: http://www.nps.org.au (follow links to Health Professionals, Topics & Resources, and select Heart Failure) (accessed Feb 2006). 5. National Institute of Clinical Studies. Let s talk about heart failure. Patient information booklet by the National Heart Foundation Australia and National institute of Clinical Studies Heart Failure Patient Resources Directory. Available at: http://www.nicsl.com.au (follow Quick Links to Heart Failure Directory) (accessed Feb 2006). 6. Australian Government Department of Veterans Affairs. Veterans MATES (Medicines Advice and Therapeutics Education Services). Available at: http://www.dva.gov.au/ health/veteransmates (accessed Feb 2006). LETTERS Read on the Web emja Most popular articles from 2/20 February issues Acute pain management: the evidence grows mac10793_fm.html Shrinking bottle syndrome www.mja.com.au/public/issues/184_04_200206/ new11124_fm.html A tender lump in the neck yel10826_fm.html Debating health workforce innovation van11144_fm.html Mifepristone (RU-486) and limits to abortion letters_060206_fm-1.html Hospital in the home: what next? letters_060206_fm-5.html The Inquiry into the Waterfall train crash: implications for medical examinations of safety-critical workers hoc10807_fm.html Health Workforce Innovation Conference bro11125_fm.html The use and misuse of performanceenhancing substances in sport orc10359_fm.html Chronic heart failure: time to recognise this major public health problem www.mja.com.au/public/issues/184_04_200206/ kru10964_fm.html MJA The Medical Journal of Australia Editor Martin Van Der Weyden, MD, FRACP, FRCPA Deputy Editors Bronwyn Gaut, MBBS, DCH, DA Ruth Armstrong, BMed Ann Gregory, MBBS, GradCertPopHealth Manager, Communications Development Craig Bingham, BA(Hons), DipEd Senior Assistant Editor Helen Randall, BSc, DipOT Assistant Editors Elsina Meyer, BSc Kerrie Lawson, BSc(Hons), PhD, MASM Tim Badgery-Parker, BSc(Hons), ELS Josephine Wall, BA, BAppSci, GradDipLib Proof Readers Christine Binskin, BSc; Sara Thomas, BSc; Rivqa Berger, BSc(Hons) Editorial Administrator Kerrie Harding Editorial Assistant Christine Hooper Production Manager Glenn Carter Production Coordinator Peter Humphries Web Assistant Peter Hollo, BSc(Hons), BA, LMusA Librarian Jackie Treadaway, BAComm(Info) Consultant Biostatistician Val Gebski, BA, MStat Content Review Committee Craig S Anderson, PhD, FRACP; Leon A Bach, PhD, FRACP; Flavia M Cicuttini, PhD, FRACP; Jennifer J Conn, FRACP, MClinEd; Marie-Louise B Dick, MPH, FRACGP; Mark F Harris, MD, FRACGP; Paul D R Johnson, PhD, FRACP; Tom Kotsimbos, MD, FRACP; Jenepher A Martin, MEd, FRACS; Campbell Thompson, MD, FRACP; Tim P Usherwood, MD, FRCGP; E Haydn Walters, DM, FRACP; Owen D Williamson, FRACS, GradDipClinEpi; Jane Young, PhD, FAFPHM; Jeffrey D Zajac, PhD, FRACP Australasian Medical Publishing Co Pty Ltd Advertising Manager: Peter Butterfield Media Coordinators: Kendall Byron; Julie Chappell The Medical Journal of Australia (MJA) is published on the 1st and 3rd Monday of each month by the Australasian Medical Publishing Company Proprietary Limited, Level 2, 26-32 Pyrmont Bridge Rd, Pyrmont, NSW 2009. 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All literary matter in the Journal is covered by copyright, and must not be reproduced, stored in a retrieval system, or transmitted in any form by electronic or mechanical means, photocopying, or recording, without written permission. Published in 2 volumes per year. Annual Subscription Rates for 2006 (Payable in Advance) to: AMPCo, Locked Bag 3030, Strawberry Hills, NSW 2012 Individual Subscriptions (includes 10% GST) Australia: $A350.00, Medical students (Australia only): $A60.00 Overseas: $A451.00 Indexes are published every 6 months and are available on request as part of the current subscription. Single or back issues contact: AMPCo (02) 9562 6666. Advice to Authors http://www.mja.com.au/public/information/instruc.html 28,406 circulation as at 30 September, 2005 ISSN 0025-729X 424 MJA Volume 184 Number 8 17 April 2006